Based on record review and interview, facility staff failed to appropriately transfer 2 (#s 2 and 4) of 16 patients reviewed who were in active labor. The facility staff failed to complete and provide the required Transfer with a Physician Certification form for the receiving hospital. The facility staff did not provide a copy of the medical record to the receiving hospital. Findings include: 1. On 4/21/15, patient #2 presented to the ED complaining of the onset of labor. The patient was 38 weeks pregnant. The EHR reflected her contractions were every 3-4 minutes. A QMP or provider did not present to the ED to complete a MSE. A phone call was received by a provider directing the nurse to send the patient to another hospital. The EHR did not reflect if the patient was stable to be transferred. The rationale as to why the patient was sent to another hospital was not reflected in the EHR. The patient did not request a transfer to another hospital. The EHR reflected a Physician Certification form was not completed. A copy of the medical record was not provided to the receiving hospital. 2. On 4/18/15, patient #4 presented to the ED complaining of being in active labor. The EHR reflected the patient was 39 weeks pregnant. The patient was dilated to 6 cm with 100 % effacement. Contractions were every 5-6 minutes. The QMP documented the patient was having active contractions and transferred the patient to another hospital. The EHR did not reflect the reason as to why the patient was transferred in an unstable condition. The patient did not request a transfer to another hospital. The EHR reflected a Physician Certification form was not completed. A copy of the medical record was not provided to the receiving hospital. In an interview on 5/13/15 at 9:30 a.m., staff member A, DON, stated both patients should not have been transferred to another hospital. The condition of both patients were not stable enough to be transferred. Staff member A stated transfer paper work was not completed or provided to the receiving hospital for both patients.

Based on observation, record review and interview, the facility was not in compliance with 42 CFR §489.20(1), and §489.24. The facility failed to provide a medical screening exam.

Based on record review and interview, the facility failed to provide a medical screening exam (MSE) for 6 (#s 1, 4, 14, 23, 24 and 28) of 28 records reviewed. Findings include: 1. On 6/29/14 patient #1 presented to the ER with her grandmother with a cough, ear pain, and a fever. The record reflected the patient had a history of asthma. The grandmother was told by the nurse the provider would not see patient #1 and to leave. A MSE was not attempted or completed by a qualified medical provider (QMP). The medical record reflected the patient left against medical advice (AMA). Review of the grievance investigation summary dated 6/30/14 from staff member A, DON, reflected the patient was denied a MSE by the provider. In an interview on 3/11/15 at 8:30 a.m., staff member A stated a MSE was denied because the grandmother did not have custody of patient #1. The provider would not see the patient. In an interview on 3/12/15 at 8:00 a.m., the grandmother stated she is raising patient #1. The grandmother stated she was very concerned for patient #1 because of her asthma. She said patient #1 was not breathing right and was complaining her ears hurt. The nurse contacted the provider on call. The nurse stated the provider would not see patient #1 because she did not have custody. The grandmother stated she left the emergency room upset. The next day the grandmother took patient #1 to another doctor. Patient #1 received medications for an ear infection and for her asthma. Review of the facility medical staff and by laws reflected if a request is made on an individuals behalf by another individual for an examination or treatment for any medical condition, the individual shall be given a Medical Screening Exam. The medical record for patient #1 reflected the patient left against medical advice (AMA) even though the provider refused to see the patient. The medical record reflected no documentation of an attempt to explain the risk and benefits of leaving AMA, why the patient refused treatment, or any attempt to have an AMA form completed. 2. On 6/30/14, patient #4 presented to the ER with fatigue, and pain in the lower back and abdomen. A MSE was not attempted or completed by a qualified medical provider (QMP). 3. On 2/28/15, patient #14 presented to the ER with a headache. A MSE was not attempted or completed by a qualified medical provider (QMP). 4. On 5/27/14, patient #23 presented to the ER with an EENT (eye, ear, nose and throat) complaint. The record reflected a history of undiagnosed cardiac murmurs. The medical record reflected the patient's ears, nose, throat and mouth were not assessed. A MSE was not completed. The medical record reflected the patient was sent to the clinic for further evaluation and treatment. 5. On 7/16/14, patient #24 presented to the ER with extremity pain. The medical record reflected a pain level was at an eight. The left wrist had a noticeable deformity. A MSE was not completed. The medical record reflected the patient was sent to the clinic for further evaluation and treatment. 6. On 7/21/14, patient #28 presented to the ER with extremity pain. The medical record reflected no history. The medical record reflected the right foot was swollen. The pain level was at a six. The medical screen exam was completed by an untrained QMP. The medical record reflected the patient was sent to the clinic for further evaluation and treatment. In an interview on 3/11/15 at 4:00 p.m., staff member A, DON, stated a contracted nurse had completed a nursing assessment. The contracted nurse was not trained to complete a MSE. She stated contracted nurses are not approved by the governing board to do a MSE. She stated patient #28 was not provided a MSE by a qualified provider. Review of the facility medical staff by laws reflected a QMP is a provider which has been approved to complete MSE with in the scope of practice. The QMP must be approved by the governing board. Review of the facility policy Emergency Medical Treatment and Active Labor Act showed a nurse was only allowed to practice within the scope of practice.